Long-acting Steroid Research Articles

Transrectal ultrasound-guided intraprostatic injection therapy for treatment of chronic prostatitis in a Ugandan population

Abstract Background Globally, the clinical understanding of prostatitis has been obscured mainly due non-specificity of clinical features, no uniform diagnostic criteria and its protracted treatment course. Conventional treatment of chronic prostatitis by oral or parenteral routes of drug administration remains a challenge basically because of the poor ability of drugs to penetrate prostate epithelium; the alternative of direct prostate injection has not been thoroughly studied in an African population. The aim of this retrospective study was to determine the effect of transrectal ultrasound (TRUS)-guided intraprostatic injection of a cocktail of antibiotics, antifungal and long-acting steroids on alleviating symptoms attributed to chronic prostatitis in Ugandan patients. Methods We conducted a retrospective review of records among patients who were referred with symptoms attributed to chronic prostatitis at the Radiology Department of Ernest Cook Ultrasound Research and Education Institute (ECUREI). Patients were treated using TRUS-guided intraprostatic injection of a cocktail of antibiotics, antifungal agents and long-acting steroids. Results At baseline, we found that out of the 131 patients, 90 had pain or burning during urination in the last week to seeking care and 89 had symptoms, which had kept them away from doing the kinds of things they would usually do. Additionally, 85 of the total number of patients felt terrible about their symptoms. Post intervention, after 1 year following completion of intraprostatic injection therapy (IPIT), we found that most patients had mild residual symptoms which were largely; mild pain and burning at urination. None of the patients had symptoms, which kept them away from doing the kind of things they would usually do. Furthermore, 62 patients felt delighted about their quality of life, whereas prior to treatment, none was delighted. Eighty-five patients had felt terrible about their quality of life prior to the IPIT, but post therapy, no patient felt terrible. Conclusion Transrectal ultrasound-guided intraprostatic injection therapy of a drug cocktail composed of antibiotics, antifungal agents, long-acting steroids and lidocaine for treatment of patients presenting with symptoms attributed to chronic prostatitis and refractory to conventional oral therapy has shown a good response in this study.

A New Ray of Hope in the Treatment of Seasonal Hyperacute Panuveitis: Could Intravitreal Triple Combination Therapy of an Antibiotic with Dual Steroids Play a Pivotal Role?

ABSTRACT Introduction Seasonal Hyperacute Panuveitis (SHAPU) is a blinding disease in Nepal with unknown aetiology. Henceforth, we proposed to study the treatment outcome of a triple intravitreal combination therapy of dual steroids triamcinolone (long-acting steroid) and dexamethasone (short-acting steroid) along with antibiotic moxifloxacin for patients with severe stage of SHAPU. Methods A prospective study was conducted among the SHAPU patients presenting in severe stages during the September to December 2023 outbreak. Intravitreal injection of 4-mg preservative-free triamcinolone acetonide (4 mg/0.1 ml) with intravitreal dexamethasone injection (0.4 mg/0.1 ml) and 0.5 mg/0.1 ml of moxifloxacin was given in the operating theatre. Best corrected visual acuity, intraocular pressure measurements, vitreous haze and fundus evaluation, were assessed to determine the treatment outcome on examination on day 7 and day 30 following intravitreal combination therapy. Result A total of 6 patients (2 female and 4 male) were enrolled. At presentation, the mean BCVA was 2.40 ± 0.30 logMAR, mean intraocular pressure was 12.8 mmHg and vitreous haze was 4+ haze in all cases. The evaluation on the 7th day and 30th after injection showed significant improvement in BCVA (p value = 0.039; p value = 0.040, respectively). The change in the IOP at day 7 (p value = 0.85) was insignificant. However, the IOP change was significant at day 30 (p value = 0.5). Similarly, there was a marked reduction in the vitreous haze with better fundus visibility after treatment. Conclusion This study depicted that steroids prevent the dreaded complication of hypotony due to ciliary shutdown by combating severe inflammation, thus adding new hope to the armamentarium of SHAPU management.

Injectable Intravitreal Fluocinolone Acetonide Implant for Chronic Postoperative CME in the Presence of Silicone Oil Tamponade

Purpose: This report describes the use of the injectable intravitreal fluocinolone acetonide 0.18mg implant (FAI) for chronic postoperative cystoid macular edema (CME) in an eye with a silicone oil-filled vitreous cavity. Methods: A retrospective chart review was performed including surgical, clinical, and imaging data. Results: The patient had multiple complicated vitreoretinal surgical procedures including long-term silicone oil tamponade. The eye developed chronic CME, which responded to intravitreal steroid therapies and subsequently received FAI for longer-term control. The eye had no complications related to FAI. Conclusion: FAI is a long-acting steroid that may be beneficial in controlling chronic CME. It can be considered for use in eyes with silicone oil tamponade, but further studies are required to better understand the pharmacokinetics and utility of the FAI when injected into silicone oil-filled vitreous cavities.

Injectable Fluocinolone Implant for the Management of Cystoid Macular Edema in Coats' Disease.

A six-year-old boy with history of Coats' disease and cystoid macular edema (CME) was treated with a combination of peripheral retinal laser, anti-vascular endothelial grown factor injections, and short-acting injectable steroids to control his disease process. Given the excellent response to shorter acting steroids and the need for general anesthesia for each procedure, the patient underwent placement of the injectable fluocinolone acetonide implant 0.18 mg (YUTIQ) with control of his CME at 30 months of follow-up. The authors conclude that a long-acting steroid implant may be beneficial in select patients with Coats' disease. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Clinical Approach to Adrenal Insufficiency

Adrenal insufficiency refers to inadequate production of glucocorticoids, mineralocorticoids, or both by the adrenal glands. This may result from dysfunction or complete destruction of the adrenal cortex (primary adrenal insufficiency), inadequate adrenocorticotropic hormone production by the pituitary (secondary adrenal insufficiency), or inadequate corticotropin-releasing hormone production by the hypothalamus (tertiary adrenal insufficiency). Diagnosis of adrenal insufficiency requires a high index of suspicion because of its nonspecific signs and symptoms. It is associated with a high morbidity and low quality of life even in patients on treatment. When it presents as adrenal crisis it has a high mortality. Glucocorticoid replacement is the mainstay of management, and this may be combined with mineralocorticoids in the case of primary adrenal insufficiency. Health care personnel must be reminded of this condition, to improve rates of early diagnosis and improve outcomes in management. In this review, we also look at the management of adrenal insufficiency in special populations and the potential role of newer long-acting steroids in the management of adrenal insufficiency is briefly discussed.

Functional Outcomes and Successful Predictors of Lumbar Transforaminal Epidural Steroid Injections (LTFESIs) for Lumbar Radiculopathy Under Fluoroscopic Guidance: A Prospective Study.

Lumbar radiculopathy, a common and debilitating condition, often necessitates a multimodal approach for effective management. Lumbar transforaminal epidural steroid injection (LTFESI) has emerged as a valuable therapeutic option when conservative measures fall short. Recent interest in long-acting and non-particulate steroids prompts a critical examination of their impact on LTFESI outcomes. This prospective study aims to evaluate the efficacy of LTFESI in improving pain and functional outcomes in patients with lumbar radiculopathy, focusing on long-acting and non-particulate steroids, and analyse the associated economic burden. The study, conducted from October 2017 to April 2019, involved 52 patients with lumbar radiculopathy meeting specific criteria. LTFESI was administered using a hospital-based prospective design. Functional outcomes were assessed using the Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) scores at various intervals. Statistical analyses were performed to identify predictors of successful outcomes. Participants (average age 43.22 years, 27 (51.92%) male) exhibited diverse Michigan State University (MSU) grade profiles and predominantly had pathology at the L4-5 level. The study demonstrated a significant and lasting functional improvement in 43 (82.69%) of patients after LTFESI. Patients with 2AB-type intervertebral disc prolapse (IVDP) showed lower response rates, emphasizing subtype influence. The efficacy of LTFESI was sustained for up to six months in almost 82.69% of patients, highlighting its potential for long-lasting benefits. The difference in the mean ODI score pre-injection and six months post-injection is statistically significant (p<0.0001). A total of four patients (7.69%) underwent surgical treatment for lumbar radiculopathy as their symptoms did not improve after injection. For all four patients (7.69%), surgery was done one month after injection. Five patients (9.61%) had ODI scores of more than 40, indicating severe disability at the end of six months. So, in nine patients (17.3%), the injection given was not effective at the end of six months, four (7.69%) of whom were operated on and five (9.61%) patients received conservative treatment. Thus, 43 (82.69%) of patients had a good outcome. The study reinforces LTFESI as an effective and safe intervention, providing substantial and lasting benefits for lumbar radiculopathy. The majority experienced immediate relief, supporting its role as an intermediate option between conservative management and surgery. Identified predictors of decreased success underscore the importance of early intervention and tailored treatment plans. The study emphasizes LTFESI's diagnostic and therapeutic potential, with economic benefits and safety highlighted. LTFESI emerges as a safe and effective intervention for lumbar radiculopathy, offering substantial and enduring pain relief. The study contributes valuable insights into the nuanced outcomes of LTFESI, including the impact of IVDP subtypes, factors influencing success, and the procedure's cost-effectiveness. While acknowledging limitations, this work adds to the growing evidence supporting LTFESI as a crucial component in the management of lumbar radiculopathy.

Injectable Fluocinolone Implant for the Management of Chronic Postsurgical Cystoid Macular Edema in Vitrectomized Eyes.

Long-acting injectable steroids are changing the treatment paradigm for patients with chronic intraocular inflammation and cystoid macular edema (CME). We report the use of the fluocinolone implant (FAI) 0.18 mg in patients with chronic postsurgical CME following pars plana vitrectomy (PPV). This is a retrospective case series of 24 vitrectomized eyes which received FAI for the management postsurgical CME. Clinical outcomes and requirement for rescue therapy were studied. Median length of follow-up was 19.3 months (range 8.3-23.2 months). There was an improvement in median central subfield thickness from 412 μm (range 167-806 μm) to 311 μm (range 157-686 μm) following FAI (p < 0.001). The injection burden decreased significantly following study treatment (p < 0.001); however, there was no significant change in visual acuity (p = 0.334). Eighteen eyes had control of CME that did not require additional intravitreal therapy. Four eyes had initially controlled but recurrent CME requiring intravitreal steroid therapy at median of 7.8 months (range 7.6-15.4 months). One eye never attained sufficient inflammatory control despite rescue therapy. FAI can be an effective treatment in vitrectomized patients with chronic postsurgical CME and can help decrease the overall injection burden.

Conservative treatment of patients with secondary adhesive capsulitis

Background. Secondary adhesive capsulitis, similar to idiopathic one, is accompanied by thickening of the glenohumeral joint capsule and loss of its elasticity. Nonoperative management of secondary adhesive capsulitis associated with shoulder soft tissue injuries, impact of prolonged immobilization or surgical treatment still remains controversial. Capsular distension with steroids as in idiopathic adhesive capsulitis is often not used for one reason or another. The purpose: to compare the results of conservative treatment in patients with secondary adhesive capsulitis who underwent or not capsular distension with steroids during the treatment. Materials and methods. From 2015 to 2021 at the Department for Microsurgery and Reconstructive-Recovery Surgery of Upper Limb of the State Institution “Institute of Traumatology and Orthopaedics of the National Academy of Medical Sciences of Ukraine” (Kyiv) and Ivano-Frankivsk Regional Clinical Hospital, we have conducted conservative treatment for 825 patients with various soft tissue pathology of the shoulder joint complicated by secondary adhesive capsulitis. All patients were divided into two groups: first one— conservative treatment, second one — conservative treatment with intraarticular injections (capsular distension) with steroids. In our study, we evaluated the function of the shoulder joint using the Constant Shoulder Score (CSS) and visual analog scale (VAS) before treatment and after 3 and 6 months. Results. Patients from first group (conservative treatment without distension intraarticular injections) had worse average functional results 3 month after starting treatment according to CSS (p=0.13) and VAS (p=0.24) compared to subjects of second group. Six months after the start of treatment, patients from first group had significantly worse results by CSS and VAS than those from group 2, where distension intraarticular injections were performed (p=0.03 and p = 0.06, respectively). Conclusions. Conservative treatment of patients with secondary adhesive capsulitis of the shoulder joint should be comprehensive, differentiated and include both non-drug treatment methods and distension intraarticular injections with long-acting steroids.

Osseous Metaplasia of the Transverse Humeral Ligament in a 10-Year-Old Bengal Cat

AbstractThis report is of an osseous metaplasia of the transverse humeral ligament and secondary bicipital tenosynovitis in a 10-year-old Bengal cat. Computed tomography revealed the presence of an osseous bridge enclosing the bicipital groove, with ultrasonography confirming partial tear and inflammation of the bicipital tendon. Initial conservative management with intra-articular long-acting steroids failed to provide long-term improvement of clinical signs. Surgical excision of the osseous lesion resulted in complete resolution of lameness after surgery, confirmed by a 1-year follow-up. Histopathology of this lesion confirmed a well-differentiated osseous metaplasia of the transverse humeral ligament.

Outcome of transforaminal epidural steroid injection for lumbar radiculopathy: initial three-year experience at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Nepal

BackgroundThe prevalence of low back pain with radiculopathy in general population varies from 9.9% to 25%, which can be due to bony narrowing of the lateral recess or due to prolapsed intervertebral disc. Transforaminal epidural injection of a mixture of long-acting anaesthetic (bupivacaine) and particulate steroids (depomedrol) has been a treatment modality in patients not responding to initial physiotherapy and neuropathic pain medications.MethodsTo analyze the effectiveness of transforaminal epidural steroid injection (TFESI) in the treatment of low back pain with radiculopathy, a retrospective case series evaluating the records of patients that received TFESI (1 mL 0.5% bupivacaine +1 ml/40 mg depomedrol) under C-arm guidance from January 2015 to December 2018 (3 years) at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), their lumbo-sacral MRI and the pre-procedure, 1-week and 3-month numeric pain rating scale, were analyzed. Successful treatment (reduction of pain scale by more than 50% of baseline at 3 months) in the patients with bony recess stenosis and those with prolapsed intervertebral disc was compared.ResultsOut of 67 patients that received TFESI, 35 (52.23%) could be followed up. The mean age was 55.8 ± 14.39 years and 51.3% were females. 68.57% had L5 and 20% had S1 radiculopathy. Bony recess stenosis was seen in the aged 40% and PIVD was the cause of radiculopathy in 60%. The median duration of radicular pain prior to intervention was 3 months. TFESI was effective as the mean numeric pain scale before injection was 8.97 ± 1.32 which reduced to 3.91 ± 3.23 (paired t test p value < 0.001) at 1 week post injection and 3.23 ± 3.34 (paired t test p value < 0.001) at 3 months post injection. Twenty-six of the 35 patients (75.29%) had more than 50% pain relief compared to baseline at 3 months and were satisfied. Nine patients continued to have pain; however, only one required a surgical intervention. The effectiveness of TFESI was not significantly different in different ages (Fisher’s exact test p value 0.182) and in different anatomic levels (Fisher’s exact test p value 0.241). Six out of eight patients with bony recess stenosis benefited as compared to 14 out of 19 patients with PIVD, though it was not statistically significant (Fischer’s exact test p value 0.688). There were no adverse events recorded.ConclusionTFESI is a safe and efficacious treatment modality in patients with radicular low back pain especially in aged patients in whom surgery under general anaesthesia is not free from risk.

Comparative study of oesophageal stricture balloon dilatation with and without triamcinolone 1% intralesional injection

Background: The objective of the study was to effect of steroids in the long term outcome of esophageal benign stricture after endoscopic balloon dilation in terms of recurrence.Methods: With purposive sampling, 50 cases were taken in these studies who were admitted with strictures at any location along the esophagus and of any size at New Civil Hospital, Surat. The indoor patients for a three year period were retrieved using a prepared case sheet proforma on the basis of the patient’s demographic profile and clinical findings. Patients had undergone endoscopic balloon dilation for esophageal benign stricture. In 25 patients endoscopic dilation was followed by submucosal injection of long-acting steroid triamcinolone and the remaining 25 patients were taken as a control.Results: All patients have normal dietary intake including solid food at the time of discharge. All patients under study were regularly followed quarterly. Overall stricture recurrence can be reduced by intralesional triamcinolone injection providing stricture length &lt;6 cm. Stricture &gt;6 cm required a repeated procedure or other treatment modalities, In study group duration between endoscopic dilatation sessions fell significantly over a post dilatation period of 3 to 12 months.Conclusions: In addition to endoscopic dilatation, intralesional trimicinolone injection is safe, effective and significantly decrease stricture rate and decrease endoscopic dilatation sessions.

Peri-operative steroids reduce pain, inflammatory response and hospitalisation length following knee arthroplasty without increased risk of acute complications: a meta-analysis.

There is no consensus regarding the risks and benefits of peri-operative steroid supplementation in total knee arthroplasty (TKA). The aim of this meta-analysis is to compare TKA protocols implemented with or without steroids in terms of pain, inflammatory response, hospitalisation length, and complications. A systematic literature search was performed on July 2019 in PubMed, Medline, Embase, Web of Science, Cochrane library, and the grey literature for a meta-analysis of RCTs comparing peri-operative analgesia protocols implemented with or without steroids. Sub-analyses considering the administration route, steroid type, and dosage were performed. The inverse variance method and the Mantel-Haenszel test were used for pooling continuous variables and for dichotomous variables, respectively. Risk of bias and quality of evidence were defined according to the Cochrane guidelines. Twenty articles were included. Steroid supplementation provides significantly lower post-operative pain from day 1 to day 4 (p < 0.05), with less opioid consumption (p = 0.05), less nausea and vomiting (p < 0.05), and greater knee range of motion (p < 0.001), thus resulting in a shorter hospitalisation length (p = 0.01). Moreover, lower C-reactive protein (p < 0.05), and IL-6 (p < 0.05) levels, but a higher blood glucose level at day 1 (p = 0.004), were documented. No significant differences were documented in all the outcomes after 4days of follow-up. These results were achieved without an increased incidence of complications. According to the results of the sub-analyses, the intravenous administration of 200 steroid equivalents of a long-acting steroid was associated with better results. Steroid supplementation of peri-operative drug protocols is effective in decreasing post-operative pain, opioid consumption, nausea and vomiting, range of motion limitation, and inflammatory markers without increasing short- and mid-term complications. Although these benefits last only the peri-operative period, steroid supplementation can reduce the length of hospitalisation after TKA. Systematic review and meta-analysis, level II.

Suboccipital steroid injection alone as a preventive treatment for cluster headache

BackgroundSuboccipital steroid injection can be used as a preventive treatment for episodic and chronic cluster headache (CH). In recent studies, prophylactic treatment has been used in addition to suboccipital steroid injection. In this study, we aimed to investigate the effectivity of the sole use of rapid- and long-acting steroid injections without prophylactic treatment in patients with episodic and chronic CH. MethodsThe retrospective study included 51 patients with episodic and chronic CH that underwent greater occipital nerve (GON) blockade with a single dose of rapid- and long-acting steroid injection without additional prophylactic treatment. The frequency, severity, and duration of attacks after GON blockade as well as the side effects and long-term outcomes were reviewed. ResultsIn 28 (54.9%) patients, no attack occurred after GON blockade and cluster bouts were aborted. Mean duration of attacks was 86.67 ± 37.45 min before the treatment. However, in the 23 patients that had at least one attack after GON blockade, the mean duration of attacks was 31.73 ± 36.10 min between post-treatment days 0–3, 29.35 ± 40.49 min between post-treatment days 4–10, 28.48 ± 42.17 min between post-treatment days 11–28, and 35.65 ± 46.55 min after the post-treatment day 28 (p < 0.001). Moreover, 10 (37.04%) out of 27 patients with episodic CH who periodically had one or two cluster bouts in a year had no CH attack at the time of the expected subsequent cluster bout. ConclusionGON blockade is a practical, reliable, and cost-effective treatment option for patients with episodic and chronic CH. Moreover, GON blockade is highly effective in reducing headache attacks and even aborting cluster bouts in CH patients without requiring additional prophylactic treatment.

A Randomized Trial of a Long-Acting Depot Corticosteroid Versus Dexamethasone to Prevent Headache Recurrence Among Patients With Acute Migraine Who Are Discharged From an Emergency Department

Migraine patients continue to report headache during the days and weeks after emergency department (ED) discharge. Dexamethasone is an evidence-based treatment of acute migraine that decreases the frequency of moderate or severe headache within 72 hours of ED discharge. We hypothesize that intramuscular methylprednisolone acetate, a long-acting steroid that remains biologically active for 14 days, will decrease the number of days with headache during the week after ED discharge by at least 1 day compared with intramuscular dexamethasone. We conducted a randomized, blinded clinical trial comparing intravenous metoclopramide at 10 mg+intramuscular dexamethasone at 10 mg with intravenous metoclopramide at 10 mg+intramuscular methylprednisolone acetate at a dose of 160 mg for patients presenting to 2 different EDs with moderate or severe migraine. Outcomes were assessed by telephone with astandardized instrument. The primary outcome was number of days with headache during the week after ED discharge. Secondary outcomes were complete freedom from headache, without the necessity of additional headache medication for the entire week after ED discharge, and medication preference, as determined by asking the patient whether he or she would want to receive the same medication again. One hundred nine patients received dexamethasone and 111 received methylprednisolone acetate. We obtained primary outcome data from 101 dexamethasone patients and 106 methylprednisolone acetate patients. Dexamethasone patients reported 3.0 headache days and methylprednisolone acetate 3.3 headache days (95% confidence interval for rounded mean difference of 0.4days: -0.4 to 1.1). Of 107 dexamethasone patients with analyzable data, 10 (9%) reported complete freedom from headache at 1 week versus 6 of 110 (5%) methylprednisolone acetate patients (95% confidence interval for difference of 4%: -3% to 11%). In the dexamethasone group, 76 of 101 (75%) patients would want the same medication again versus 75 of 106 (71%) of methylprednisolone acetate patients (95% confidence interval for difference of 4%: -8% to 17%). Other than injection site reactions, which were more common in the methylprednisolone acetate group, there were no substantial differences in frequency of adverse events. Methylprednisolone acetate does not decrease the frequency of post-ED discharge headache days compared withdexamethasone. Most migraine patients are likely to continue to experience headache during the week after ED discharge.

Prevalence, predictors, and outcomes of steroid-induced hyperglycemia in hospitalized patients with hematologic malignancies.

To determine prevalence, predictors, and outcomes of steroid-induced hyperglycemia in hospitalized patients with hematologic malignancies METHODS: We performed retrospective analysis of patients who were hospitalized on any of the four hematology services or bone marrow transplant service and who received systemic steroids during a 2-month period. Mean glucoses for days 1-4 and maximum glucose were calculated and the total daily steroid dose was converted to equivalent dose of dexamethasone. Hyperglycemia was defined as any glucose >9.917 mmol/l during days 1-4. We examined associations between variables using Spearman's correlations and multivariable linear regression RESULTS: 168 patients were included in the analysis. Mean age was 57.1 ± 14.4 years with 59% males and 90% Caucasians. The prevalence of hyperglycemia was 39%. Eight patients received intravenous insulin. In patients without diabetes, steroid dose equivalent to >12 mg dexamethasone and longer acting steroids caused greater degree of hyperglycemia compared to a dose <12 mg. Maximum glucose was a predictor of hospital length of stay among patients without diabetes (but not those with diabetes), and with acute leukemia or stem cell transplant (but not other hematologic malignancies). There were no significant differences in in mortality or other outcomes between the groups with and without hyperglycemia CONCLUSIONS: Hyperglycemia is common in patients with hematologic malignancies, which require frequent corticosteroids. Higher steroid dose and long-acting steroids caused a greater degree of hyperglycemia. Maximum glucose was a predictor of length of stay but this was only significant for patients without diabetes, those with acute hematologic malignancy or stem cell transplant.

Влияние кортикостероидов пролонгированного действия на структурные и функциональные особенности сетчатки у пациентов с транссудативной отслойкой пигментного эпителия сетчатки при возрастной дегенерации макулы

Влияние кортикостероидов пролонгированного действия на структурные и функциональные особенности сетчатки у пациентов с транссудативной отслойкой пигментного эпителия сетчатки при возрастной дегенерации макулы

Medical therapies for heavy menstrual bleeding in women with uterine fibroids: a retrospective analysis of a large commercially insured population in the USA

To report patterns and patient characteristics associated with initiation of and persistence with medical therapies for uterine fibroid-related heavy menstrual bleeding. Retrospective cohort study. US commercial insurance claims database. 41561 women aged 18-54years with uterine fibroids and heavy menstrual bleeding who initiated medical therapies from January 2000 through December 2013. Multinomial logistic regression was used to assess patient characteristics associated with initiation and persistence. Cox proportional hazards regression was used on propensity score-matched cohorts to examine change from index medication. Initiation of and persistence with four first-line medical therapies: short- and long-acting reversible contraceptive steroids, leuprolide acetate, and tranexamic acid. Most women (79.4%) took short-acting reversible contraceptive steroids as first-line therapy (index medication), whereas 9.5%, 8.5%, and 2.7% used long-acting reversible contraceptive steroids, leuprolide acetate, and tranexamic acid, respectively. During follow-up, 16594 women (39.9%) switched to nonindex medication (18.4%) or procedural treatment (81.6%). In comparison with women taking short-acting steroids, those receiving long-acting steroids were less likely to switch [hazard ratio (HR) 0.84, 95% CI 0.79-0.91], whereas women taking leuprolide acetate (HR 2.44, 95% CI 2.27-2.62) or tranexamic acid (HR 1.44, 95% CI 1.26-1.65) were more likely to switch. Older age, emergency department visits, anaemia, and inflammatory disease diagnoses at baseline were associated with increased probability of discontinuing the index medication or switching to another therapy. Women with uterine fibroid-related heavy menstrual bleeding were more likely to persist with their initial therapy of long-acting reversible contraceptive steroid compared with other medical options. 80% women with fibroid-related heavy menstrual bleeding use SARC, but LARC users are more persistent.

Self-administration of progesterone and synthetic neuroactive steroids by male rhesus monkeys

BackgroundProgesterone-derived neuroactive steroids have shown promise clinically (e.g., anti-seizure medications) but, as with other GABAA receptor modulators (e.g., benzodiazepines), may have the potential for abuse. MethodsWe evaluated the reinforcing effects of progesterone, a steroid precursor of endogenous neuroactive steroids, with and without pretreatments with the neuroactive steroid synthesis inhibitor, finasteride, in rhesus monkeys trained under a progressive-ratio (PR) schedule of i.v. midazolam injection. We also assessed reinforcing effects of the short-acting neuroactive steroid alphaxolone and the long-acting neuroactive steroid ganaxolone in comparison with the short-acting benzodiazepine triazolam and the long-acting benzodiazepine clonazepam. ResultsAt least one dose of progesterone, alphaxolone, and ganaxolone was self-administered significantly above vehicle levels in all monkeys tested (n=4 for progesterone, n=3 for alphaxolone and ganaxolone). The 5α-reductase inhibitor finasteride attenuated progesterone self-administration, consistent with the reinforcing effects of progesterone being mediated by the in vivo synthesis of neuroactive steroids. The comparison drugs, triazolam and clonazepam, were self-administered significantly above vehicle by all monkeys. Although the maximum number of injections/session maintained by the neuroactive steroids was below that maintained by the midazolam training dose, analysis of break points (i.e., highest response requirement achieved) suggested modest differences in relative reinforcing effectiveness for neuroactive steroids compared with benzodiazepines. ConclusionsOur results are consistent with endogenous and synthetic neuroactive steroids having reinforcing effects similar to that of benzodiazepines, with reinforcing effectiveness possibly lower for the neuroactive steroids compared with benzodiazepines based on some measures.

Chronic Obstructive Pulmonary Disease and Pulmonary Hypertension in a Patient With Klippel-Feil Syndrome: A Rare Association

SESSION TITLE: Airways Global Case Reports I SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Klippel-Feil syndrome (KFS) is a rare condition associated with multiple congenital anomalies. It's actual incidence is unknown. Nevertheless, it has been estimated that it occurs in approximately 1 in 40,000 to 42,000 newborns. Reported cases with pulmonary involvement includes agenesis and hypoplasia of the lung, pulmonary hypertension (PH) and bronchial asthma. To our knowledge, chronic obstructive pulmonary disease (COPD) with pulmonary hypertension in a patient with KFS has never been cited in the literature, hence we report the finding in a patient with such an association. CASE PRESENTATION: A 54-year-old obese Filipino male diagnosed with congenital heart disease (patent foramen ovale) and hypertension was admitted at the Philippine Heart Center due to progressive dyspnea and non productive cough for twelve days. He was a previous 30-pack year smoker. Physical examination revealed a short statured-individual with low hairline, short and webbing of the neck. He has evident chest wall deformity associated with thoracolumbar scoliosis. He was in cardio-respiratory distress. Auscultation of the chest showed bibasal crackles and expiratory wheezes. Arterial blood gas analysis showed an acute respiratory acidosis with adequate oxygenation, hence he required assisted mechanical ventilatory support. Chest radiograph showed mild pulmonary congestion with pneumonic infiltrates and magnified heart. Electrocardiogram showed nonspecific ST-T wave changes with right axis deviation. Troponin I was elevated. He was then started with acute coronary syndrome regimen, antibiotics and inhaled short-acting bronchodilator. Echocardiography showed dilated right ventricle with hypertrophy and dilated main pulmonary artery with mild PH (48 mmHg). In lieu with the acute renal failure, he was referred to a nephrologist. A request of kidney ultrasound showed absent right kidney. In line with the clinical features KFS a radiography of the spine showed fusion of C1 and basal output and multiple fusion of C2, C3 and C4 cervical vertebrae, hence confirming the diagnosis. Pulmonary function test showed very severe obstructive ventilatory defect with no significant response to bronchodilator, hence a diagnosis of severe COPD was made. He was successfully liberated from ventilatory support and discharged after 3 weeks of hospitalization with treatment of inhaled long-acting bronchodilator plus steroid. DISCUSSION: Klippel-Feil syndrome is a rare skeletal disorder primarily characterized by abnormal union of two or more cervical vertebrae. The triad of low hairline, short neck and limited neck movement which are present in the case remains to be the hallmark of the disorder. Moreover, involvement of visceral anomalies such as patent foramen ovale and right kidney agenesis merely defined the diagnosis. The association with COPD and PH is yet to be highlighted since no reports are available in the literature. Nevertheless, with the patient's history of chronic smoking provides a strong risk factor for the development of severe airflow obstruction. The presence of patent foramen ovale is rare in this case and poses no effect in the development of PH. The combined effects of hypoxic pulmonary vasoconstriction, inflammation and loss of pulmonary capillaries due to severe COPD could be the main insult. Furthermore, Suga et al explained the contributory effect of thoracic deformity in PH. This is due to hypoventilation and restriction of the pulmonary vascular bed causing reactive pulmonary arterial vasoconstriction. Treatment of patients with KFS is directed on associated anomalies or co-morbidities. In this case, management of acute respiratory failure due to complicating comorbidities was made. CONCLUSIONS: Klippel-Feil syndrome is a clinically well recognized disorder and commonly associated with many congenital malformations. Although rare, COPD and PH may occur with this syndrome. Clinicians should be directed towards detecting associated anomalies or co-morbidities for appropriate management. Reference #1: Klippel M, Feil A. “Un cas d'absence des vertebres cervicales. Avec cage thoracique remontant jusqu'a la base du crane (cage thoracique cervicale)”. Nouv Iconog Salpetriere 1912. 25: 223-250. Reference #2: Tracy M, Dormans JP,. Klippel-Feil syndrome: clinical features and current understanding of etiology. Clin Orthop Relat Res 2004; (424): 183-90 Reference #3: Suga K, Motoyama K, Hara A, Kume N et al. Respiratory failure and pulmonary hypertension associated with KFS. Annals of nuclear medicine 1999. 13(6): 441-446. DISCLOSURE: The following authors have nothing to disclose: Edgardo Tiglao, Teresita DeGuia, Maria Paz Mateo No Product/Research Disclosure Information

PIH1 - comparing Medical Therapies For Heavy Menstrual Bleeding Related To Uterine Fibroids

Uterine fibroids (UF) affect more than one-fifth of US reproductive age women. While multiple medical therapies are available, there are little data on how long patients stay on a medical therapy before they switch to other medications or procedural treatment. Identifying successful and lasting medical therapies would better inform patients and providers, and reduce the number of hysterectomies. This study compares four medication classes (short-acting reversible contraceptive steroids (SARC), long-acting reversible contraceptive steroids (LARC), leuprolide acetate (LA) and tranexamic acid (TA) for controlling heavy menstrual bleeding (HMB) in UF patients. Using a large private health insurance claims database (Optum Labs Data Warehouse), we identified women aged 18-54 with UF and HMB diagnoses and medical therapy between 2000 and 2013. We defined patients’ first medication after diagnosis as the index medication (and the study drug cohorts), and assessed the duration of their index medical therapy and whether they switched. Propensity score matching and survival analysis were used to compare different medications. Of the 41,561 eligible women, the four drug cohorts had 33,000 (79.4%: SARC), 3,928 (9.5%: LARC), 3,525 (8.5%: LA), and 1,108 (2.7%: TA), respectively. 16,594 (40.0%) switched to non-index medication or procedural treatment. Among the patients who switched, 45.7% switched to hysterectomy, 24.1% switched to endometrial ablation, 8.5% switched to myomectomy, and 18.4% switched to another medication class. Patients on LARC were much less likely to switch in the short term (e.g., within 60 days), but the effect was similar to SARC in the long term (on average HR=0.63, p<0.001). Patients on leuprolide acetate (HR=2.41, p<0.001) and tranexamic acid (HR=1.49, p<0.001) were more likely to switch, compared to those on SARC. When treating HMB related to UF, women are more likely to stay on medications that have contraceptive benefits (i.e., LARC and SARC), compared to leuprolide acetate and tranexamic acid.